J Bone Joint Surg Am. 2025 Jul 10. doi: 10.2106/JBJS.24.01565. Online ahead of print.

ABSTRACT

BACKGROUND: Race and ethnicity and insurance status have been identified as major contributors to disparities in health care. Several studies have analyzed racial and ethnic disparities in patients with private and government insurances, but very little is known about disparities in managed care models. Kaiser Permanente (KP) is a health-care organization (health maintenance organization, HMO) within the managed health-care system. It provides integrated care through its network of facilities and doctors, with equal access to all of its beneficiaries. Hence, the objective of this study was to determine whether there are health-care disparities in spinal fusion outcomes among patients enrolled in a managed health-care system such as Kaiser Permanente.

METHODS: Using data from the KP Spine Registry, we performed a retrospective cohort study of adults ≥18 years of age who underwent spinal fusion. The predictor was race/ethnicity (White [reference], Black, Hispanic, Asian). The primary outcome was reoperations, and the secondary outcomes were 90-day emergency department (ED) visits, 90-day readmissions, and 90-day and 1-year mortality. Multivariable Cox regression and logistic regression models were used to adjust for confounders.

RESULTS: We included 40,258 patients with spinal fusions. A lower reoperation risk was observed for Black (hazard ratio [HR] = 0.90; 95% confidence interval [CI] = 0.82 to 0.99; p = 0.038), Hispanic (HR = 0.78; 95% CI = 0.71 to 0.85; p < 0.001), and Asian (HR = 0.62; 95% CI = 0.55 to 0.71; p < 0.001) patients. Black (odds ratio [OR] = 1.25; 95% CI = 1.14 to 1.36; p < 0.001) and Hispanic (OR = 1.15; 95% CI = 1.07 to 1.25; p < 0.001) patients had a higher likelihood of an ED visit within 90 days. A higher likelihood of readmission within 90 days was also observed for Black patients (OR = 1.18; 95% CI = 1.05 to 1.32; p = 0.005). No significant differences in 90-day and 1-year mortality were observed.

CONCLUSIONS: Despite equal access to spine surgery in a managed health-care system such as Kaiser Permanente, our study showed that some disparities exist among Black and Hispanic patients. We believe that managed care networks can reduce disparities relative to other health-care delivery systems, although more work needs to be done to ensure equitable outcomes in all domains. These findings underscore the urgent need to address these disparities with further research.

LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

PMID:40638682 | DOI:10.2106/JBJS.24.01565

Int Orthop. 2025 Jul 11. doi: 10.1007/s00264-025-06603-3. Online ahead of print.

ABSTRACT

PURPOSE: Aneurysmal bone cysts (ABCs) are bone tumours characterised by blood-filled cystic lesions. Management strategies for ABCs vary widely and lack consensus. This study aims to evaluate outcomes in 258 patients and investigate the factors affecting the recurrence rates.

METHODS: This study is a single-centre retrospective analysis of patients diagnosed with ABC between January 1990 and December 2020. Patients who were histologically diagnosed with ABC, had available pathology, radiology, and surgery records, and were followed up for at least 24 months were included. Secondary ABCs were excluded. Presenting symptoms and location, computerised tomography (CT) and magnetic resonance imaging (MRI), treatment modalities, and recurrence were investigated.

RESULTS: The mean age of the 258 ABC patients was 17.25 ± 12.37 years, 67.44% being under 18 years, and 12.40% under five years. 49.45% were female. The average follow-up duration was 47.80 ± 41.92 months. Pain was the most common presenting symptom, reported by 79.97% of patients. 5.04% were asymptomatic and diagnosed incidentally, whereas 11.63% were diagnosed following a pathological fracture. The median disease-free survival was ten months, with the average time to first recurrence being 24.22 ± 22.14 months. Recurrence was more common in patients under five years of age (34.38% vs. 19.03%, p = 0.046) and in those with pathologic fractures (40.00% vs. 18.42%, p = 0.006). Conversely, recurrence was less common when burr and/or cautery was added to curettage (31.97% vs. 11.03%, p < 0.001). Time to recurrence was significantly shorter in cases with soft tissue oedema (median 5 vs. 12 months, p = 0.010) or fluid-fluid levels (median 6 vs. 12 months, p = 0.038).

CONCLUSIONS: The study found that pathological fractures and age under five years are associated with a higher risk of recurrence in aneurysmal bone cysts. Electrocauterization and/or high-speed burring as local adjuvant therapy is associated with low recurrence rates.

PMID:40640436 | DOI:10.1007/s00264-025-06603-3

Int Orthop. 2025 Jul 11. doi: 10.1007/s00264-025-06607-z. Online ahead of print.

ABSTRACT

PURPOSE: This investigation examined return-to-sport (RTS) outcomes and performance determinants following surgical fixation of acetabular fractures in young athletes. The primary objectives were to quantify RTS rates, evaluate functional outcomes, and identify key predictors of athletic recovery.

METHODS: We conducted a retrospective analysis of 62 patients (mean age: 29.6 years) who underwent acetabular fracture fixation at a tertiary care centre. The investigation encompassed pre- and post-operative athletic participation, patient satisfaction metrics, and psychological readiness assessments. Primary outcome measures included stratified RTS rates, with functional and psychological parameters evaluated using the Copenhagen Hip and Groin Outcome Score (HAGOS) and Hip Return to Sport after Injury (Hip-RSI) scale.

RESULTS: While 82.3% of patients resumed athletic activities, 53.2% returned to their primary sport, with only 19.4% achieving pre-injury performance levels. Multivariate analysis revealed that superior articular reduction quality and elevated psychological readiness scores, as measured by the Hip-RSI, were significant predictors of successful RTS outcomes.

CONCLUSION: Despite encouraging overall RTS rates, restoration of pre-injury athletic performance remains challenging. The study highlights the critical role of both psychological preparedness and anatomical reduction quality in optimizing outcomes.

PMID:40640435 | DOI:10.1007/s00264-025-06607-z

Injury. 2025 Jul 4;56(8):112579. doi: 10.1016/j.injury.2025.112579. Online ahead of print.

NO ABSTRACT

PMID:40633323 | DOI:10.1016/j.injury.2025.112579

Int Orthop. 2025 Jul 10. doi: 10.1007/s00264-025-06609-x. Online ahead of print.

NO ABSTRACT

PMID:40634775 | DOI:10.1007/s00264-025-06609-x

Int Orthop. 2025 Jul 10. doi: 10.1007/s00264-025-06584-3. Online ahead of print.

NO ABSTRACT

PMID:40634774 | DOI:10.1007/s00264-025-06584-3

Int Orthop. 2025 Jul 10. doi: 10.1007/s00264-025-06605-1. Online ahead of print.

ABSTRACT

PURPOSE: Management of blood transfusion in the peri-operative period of joint arthroplasties is often difficult and although associated risk factors and practice trends help ease this process, for shoulder arthroplasty, these aspects have not been explored as widely as other procedures. The purposes of the current study were to identify the incidence, risk factors and trends of blood transfusion in shoulder arthroplasty patients over a 25-year period in a single, high-volume centre.

METHODS: We retrospectively reviewed all patients undergoing hemi-, total and reverse shoulder arthroplasties, including revision procedures, between 1997 and 2021. Overall rate of blood transfusion, procedure and patient related risk factors, and transfusion trends over time were evaluated.

RESULTS: A total of 3,168 patients were included in the analysis and overall rate of blood transfusion was 1.8%. Multivariate analysis revealed revision procedure (p < 0.001), prior revision (p = 0.035), regional anaesthesia (p = 0.004), history of hypertension (p = 0.043), history of myocardial infarction (p = 0.004), history of renal insufficiency (p = 0.045), and alcohol abuse (p = 0.033) were independent risk factors for transfusion. Although transfusion rates were observed to be increased after 2007, from 0.6 to 0.8 to over 2%, this trend did not demonstrate statistical significance.

CONCLUSION: Revision procedures and regional anaesthesia as well as hypertension, myocardial infarction, renal insufficiency and alcohol abuse can be regarded as independent risk factors for blood transfusion in shoulder arthroplasty. It is imperative to implement advanced blood conservation protocols for patients with these risk factors.

PMID:40634773 | DOI:10.1007/s00264-025-06605-1

Int Orthop. 2025 Jul 10. doi: 10.1007/s00264-025-06606-0. Online ahead of print.

ABSTRACT

PURPOSE: The objective was to assess whether the size of the supraspinatus tendon retraction following a degenerative full-thickness rotator cuff tear influenced the functional outcome after arthroscopic direct repair.

METHODS: A prospective comparative cohort study of 65 patients underwent arthroscopic rotator cuff repair with a follow-up of 24 months. The mean age was 60.0 years (SD, 9.2). According to the supraspinatus tendon retraction, patients were included into the shorter retraction group (≤ 20 mm; n = 32) and longer retraction group (> 20 mm; n = 33). Clinical outcomes were assessed with the Constant-Murley score and visual analogue scale for pain. Radiological evaluation included magnetic resonance imaging (MRI).

RESULTS: Postoperatively, both groups significantly improved functional and pain outcomes, with no significant differences at the final follow-up (p = 0.671). The mean time interval between the onset of patient-reported symptoms and surgery was not significantly correlated with the retraction size (r = 0.12, p = 0.066). The multivariate analysis did not show significant predictors of satisfactory functional outcome, especially the tendon retraction size (OR 1.0; 95% CI 0.9-1.1; p = 0.728).

CONCLUSION: In degenerative tears, the size of the supraspinatus tendon retraction was not correlated with the duration of the symptoms. The tendon retraction of up to 4 cm did not influence the functional outcome at 24 postoperative months, regardless of the arthroscopic repair technique of one or two rows.

PMID:40634772 | DOI:10.1007/s00264-025-06606-0

Int Orthop. 2025 Jul 10. doi: 10.1007/s00264-025-06610-4. Online ahead of print.

NO ABSTRACT

PMID:40634771 | DOI:10.1007/s00264-025-06610-4

Injury. 2025 Jul 1:112569. doi: 10.1016/j.injury.2025.112569. Online ahead of print.

ABSTRACT

INTRODUCTION: Rib fractures are associated with substantial morbidity and mortality. Ultrasound-guided erector spinae plane block (ESPB) is increasingly used to manage pain in patients with rib fractures. However, ESPBs are often performed by proceduralists with extensive experience in regional anesthesia. The purpose of this study was to determine whether nonspecialized physicians could effectively perform ESPBs in patients with rib fracture pain in the emergency department.

METHODS: In a prospective convenience sample of 19 patients who came to the emergency department with rib fractures, ESPBs were performed by resident physicians under the supervision of experienced attending physicians. Pain scores, opioid use in morphine milligram equivalents (MME) per day, forced vital capacity, and maximum inspiratory pressure (MIP) were compared before and at several time points after ESPB.

RESULTS: Pain scores were higher before ESPB (median [IQR], 7.0 [6.0-8.0]) than at any time point after the procedure (P = .018). Median (IQR) opioid usage before ESPB was 57.6 (43.5-92.6) MME/d, which was significantly reduced at 24 h after ESPB (median [IQR], 51.5 [29.5-82.9] MME/d; P = .020) and during the remainder of the patients' stay (median [IQR], 33.8 [9.6-50.7] MME/d; P = .003). Further analyses showed that MIP before ESPB (median [IQR], 27.5 [6.3-32.5] cm H2O) was significantly lower than that at 0 to 6 h (median [IQR], 40.0 [35.0-60.0] cm H2O; P = .040), 12 to 18 h (median [IQR], 49.0 [30.0-60.0] cm H2O; P = .039), and 18 to 24 h (median [IQR], 60.0 [35.0-60.0] cm H2O; P = .028) after ESPB. No complications, 30-day readmissions, adverse events, or deaths occurred.

CONCLUSION: When adequately educated and supervised by experienced physicians, nonspecialized proceduralists can safely perform the ESPB procedure in the emergency department to provide effective analgesia to patients with rib fractures. ESPBs significantly decreased pain scores, reduced opioid usage, and improved respiratory mechanics.

PMID:40628600 | DOI:10.1016/j.injury.2025.112569

Injury. 2025 Jun 27:112565. doi: 10.1016/j.injury.2025.112565. Online ahead of print.

NO ABSTRACT

PMID:40628599 | DOI:10.1016/j.injury.2025.112565

Injury. 2025 Jul 3:112582. doi: 10.1016/j.injury.2025.112582. Online ahead of print.

NO ABSTRACT

PMID:40628598 | DOI:10.1016/j.injury.2025.112582

Injury. 2025 Jul 3;56(8):112584. doi: 10.1016/j.injury.2025.112584. Online ahead of print.

NO ABSTRACT

PMID:40627998 | DOI:10.1016/j.injury.2025.112584

Injury. 2025 Jul 2;56(8):112572. doi: 10.1016/j.injury.2025.112572. Online ahead of print.

ABSTRACT

BACKGROUND: There is a plethora of literature regarding hip fracture care, including care standards, use of registry/clinical audit data for improvement, benchmarking and outcomes. There is, however, very little published information describing how to establish and govern a national hip fracture audit. To explore the availability of information about hip fracture national clinical audit (NCA) development and governance, a scoping review was conducted.

METHODS: Electronic searches of MEDLINE (Ovid), Embase (Elsevier) and CINAHL (EBSCOHost) were conducted for articles describing national hip fracture clinical audits, published in English between 1988 and 2024. Factors for establishing the governance of a national hip fracture clinical audit were extracted and reported. Findings were shared with knowledge users from the Global Fragility Fracture Network (FFN) Hip Fracture Audit Special Interest Group and the Irish Hip Fracture Database Governance Committee to ascertain their completeness and validity. Descriptive analysis was used to summarise findings.

RESULTS: Thirteen articles were eligible for inclusion, representing 60 % of the known established hip fracture NCAs. From these, 11 components for the governance of hip fracture NCAs were identified, however the level of detail varied across the included articles. At least one of these components appeared in 83 % of the included articles, suggesting substantial consistency across hip fracture NCAs. Notably, five articles provided descriptions of all 11 components.

CONCLUSIONS: Overall, there was congruency in the approach taken to establish the governance of hip fracture NCAs and therefore the components identified could be used to support existing and emerging hip fracture NCAs in their development and sustainability.

PMID:40627997 | DOI:10.1016/j.injury.2025.112572

J Bone Joint Surg Am. 2025 Jul 8. doi: 10.2106/JBJS.24.01429. Online ahead of print.

ABSTRACT

BACKGROUND: Privacy-preserving large language models (PP-LLMs) hold potential for assisting clinicians with documentation. We evaluated a PP-LLM to improve the clinical information on radiology request forms for musculoskeletal magnetic resonance imaging (MRI) and to automate protocoling, which ensures that the most appropriate imaging is performed.

METHODS: The present retrospective study included musculoskeletal MRI radiology request forms that had been randomly collected from June to December 2023. Studies without electronic medical record (EMR) entries were excluded. An institutional PP-LLM (Claude Sonnet 3.5) augmented the original radiology request forms by mining EMRs, and, in combination with rule-based processing of the LLM outputs, suggested appropriate protocols using institutional guidelines. Clinical information on the original and PP-LLM radiology request forms were compared with use of the RI-RADS (Reason for exam Imaging Reporting and Data System) grading by 2 musculoskeletal (MSK) radiologists independently (MSK1, with 13 years of experience, and MSK2, with 11 years of experience). These radiologists established a consensus reference standard for protocoling, against which the PP-LLM and of 2 second-year board-certified radiologists (RAD1 and RAD2) were compared. Inter-rater reliability was assessed with use of the Gwet AC1, and the percentage agreement with the reference standard was calculated.

RESULTS: Overall, 500 musculoskeletal MRI radiology request forms were analyzed for 407 patients (202 women and 205 men with a mean age [and standard deviation] of 50.3 ± 19.5 years) across a range of anatomical regions, including the spine/pelvis (143 MRI scans; 28.6%), upper extremity (169 scans; 33.8%) and lower extremity (188 scans; 37.6%). Two hundred and twenty-two (44.4%) of the 500 MRI scans required contrast. The clinical information provided in the PP-LLM-augmented radiology request forms was rated as superior to that in the original requests. Only 0.4% to 0.6% of PP-LLM radiology request forms were rated as limited/deficient, compared with 12.4% to 22.6% of the original requests (p < 0.001). Almost-perfect inter-rater reliability was observed for LLM-enhanced requests (AC1 = 0.99; 95% confidence interval [CI], 0.99 to 1.0), compared with substantial agreement for the original forms (AC1 = 0.62; 95% CI, 0.56 to 0.67). For protocoling, MSK1 and MSK2 showed almost-perfect agreement on the region/coverage (AC1 = 0.96; 95% CI, 0.95 to 0.98) and contrast requirement (AC1 = 0.98; 95% CI, 0.97 to 0.99). Compared with the consensus reference standard, protocoling accuracy for the PP-LLM was 95.8% (95% CI, 94.0% to 97.6%), which was significantly higher than that for both RAD1 (88.6%; 95% CI, 85.8% to 91.4%) and RAD2 (88.2%; 95% CI, 85.4% to 91.0%) (p < 0.001 for both).

CONCLUSIONS: Musculoskeletal MRI request form augmentation with an institutional LLM provided superior clinical information and improved protocoling accuracy compared with clinician requests and non-MSK-trained radiologists. Institutional adoption of such LLMs could enhance the appropriateness of MRI utilization and patient care.

LEVEL OF EVIDENCE: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

PMID:40627696 | DOI:10.2106/JBJS.24.01429

J Bone Joint Surg Am. 2025 Jul 8. doi: 10.2106/JBJS.24.01030. Online ahead of print.

ABSTRACT

BACKGROUND: Postoperative urinary retention (POUR), a common complication after spine surgery, can contribute to longer hospital stays, urinary tract infection, pain, and morbidity. This study aimed to determine the incidence of POUR in patients who underwent lumbar decompression and to construct a predictive model for preoperatively identifying high-risk patients.

METHODS: This was a retrospective review of patients undergoing primary lumbar decompression from 2017 to 2023. Demographic characteristics, comorbidities, and perioperative data were collected. Factors associated with POUR were assessed, and multivariable logistic regressions were performed to identify independent predictors of the development of POUR. A nomogram to predict the development of POUR was developed within a training subset, based on a multivariable logistic regression model of preoperative variables, followed by the internal validation of the model in a validation subset and assessment of its performance.

RESULTS: Of the 1,938 patients included in this study, 133 (6.9%) developed POUR. Following multivariable analysis, the following risk factors for POUR were identified: a history of urinary retention (odds ratio [OR], 4.956 [95% confidence interval (CI), 2.157 to 11.383]; p < 0.001), insurance that was not commercial (private) (OR, 2.256 [95% CI, 1.298 to 3.922]; p = 0.004), intraoperative Foley catheter use (OR, 5.967 [95% CI, 3.506 to 10.156]; p < 0.001), inpatient opioid consumption of >93 morphine milligram equivalents (OR, 1.898 [95% CI, 1.220 to 2.952]; p = 0.004), and anticholinergic medication use during hospitalization (OR, 3.450 [95% CI, 2.313 to 5.148]; p < 0.001). The nomogram, which included the preoperative variables of male sex, age of >65 years, history of urinary retention, history of benign prostatic hyperplasia, not having commercial insurance, and American Society of Anesthesiologists (ASA) classification of >2, demonstrated good discrimination in the training subset (area under the curve [AUC], 0.725 [95% CI, 0.673 to 0.776]) and the validation subset (AUC, 0.709 [95% CI, 0.599 to 0.819]). The Hosmer-Lemeshow goodness-of-fit test demonstrated that the model fit the data well (chi-square test = 9.063; p = 0.170).

CONCLUSIONS: The incidence of POUR after lumbar decompression surgery was found to be 6.9%. A history of urinary retention, not having commercial (private) insurance, intraoperative Foley catheter usage, inpatient opioid consumption of >93 morphine milligram equivalents, and the administration of anticholinergic medication during hospitalization increased the risk of developing POUR. Furthermore, we constructed a preoperative predictive model with good performance metrics to help clinicians to identify patients at elevated risk for developing POUR.

LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

PMID:40627681 | DOI:10.2106/JBJS.24.01030

J Bone Joint Surg Am. 2025 Jul 8. doi: 10.2106/JBJS.24.01169. Online ahead of print.

ABSTRACT

BACKGROUND: Whether the fixation of pertrochanteric and intertrochanteric fragility fractures impacts the risk of subsequent peri-implant fracture remains unclear. We hypothesized that peri-implant fracture after an index pertrochanteric or intertrochanteric fragility fracture is associated with fixation that does not reach the distal metaphysis (non-spanning fixation).

METHODS: Retrospective chart review was performed of patients treated for index pertrochanteric and intertrochanteric femoral fragility fractures at 2 health-care systems between January 1, 2005, and January 1, 2018. Cases were categorized by whether or not fixation reached the distal metaphysis (spanning compared with non-spanning). Kaplan-Meier survival analyses estimated cumulative incidences of peri-implant fracture stratified by patient, injury, and treatment characteristics, with hazard ratios (HRs) reported when significant. We also assessed whether spanning or non-spanning fixation was associated with a contralateral femoral fracture (a proxy for patient-related fracture risk). Significance was set at p < 0.05.

RESULTS: In this study, 913 patients with a median age of 80 years had a median follow-up of 5 months (interquartile range [IQR], 3 weeks to 2.7 years). The OTA/AO classification included 388 type 31-A1 fractures, 324 type 31-A2 fractures, and 201 type 31-A3 fractures. There were 18 subsequent peri-implant fractures (1.9%) and 40 subsequent contralateral femoral fractures (4.4%). The cumulative incidence of peri-implant fracture was lower over time (p < 0.01) with spanning fixation (0% prior to 1 year) compared with non-spanning (3.3% prior to 1 year). The HR of spanning fixation for the entire time period was 0.14 (95% confidence interval, 0.03 to 0.62; p < 0.01). Peri-implant fracture risk was greater with non-spanning plates (p < 0.01) and non-spanning nails (p < 0.01) than spanning fixation, with cumulative 1-year incidences of 3.5% for non-spanning plates, 2.6% for non-spanning nails, and 0% for spanning fixation. Peri-implant fracture was not associated with other variables (p > 0.05). Contralateral fracture was not associated with the fixation group (p = 0.77), tempering concern regarding potential bias.

CONCLUSIONS: Spanning fixation following pertrochanteric and intertrochanteric femoral fragility fractures mitigates the risk of a peri-implant fracture. However, the choice of fixation for a given patient requires that this risk be considered within the greater context of surgical decision-making.

LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

PMID:40627679 | DOI:10.2106/JBJS.24.01169

Int Orthop. 2025 Jul 7. doi: 10.1007/s00264-025-06602-4. Online ahead of print.

NO ABSTRACT

PMID:40622391 | DOI:10.1007/s00264-025-06602-4

Injury. 2025 Jun 30;56(8):112576. doi: 10.1016/j.injury.2025.112576. Online ahead of print.

ABSTRACT

BACKGROUND: Bone mineral density (BMD) is a known risk factor for fragility fractures, yet its relationship with specific sacral fracture morphologies, particularly H-type fractures, is not well understood.

OBJECTIVES: To evaluate whether CT-derived Hounsfield Units (HU) correlate with the complexity of sacral fractures, focusing on H-type fracture patterns.

METHODS: A retrospective study was conducted involving 164 elderly patients (≥60 years) with sacral fractures. HU values were measured at the L5 vertebral body using CT imaging. Fractures were classified by Fragility Fractures of the Pelvis (FFP) classification and Denis zones. Logistic regression models were developed to identify predictors of H-type fractures. Model performance was evaluated using accuracy, AUC, precision, and recall.

RESULTS: Among 164 patients, 59 (36 %) had H-type fractures. FFP classifications were distributed as follows: FFP II (n = 68), FFP III (n = 18), and FFP IV (n = 78). HU did not significantly differ across FFP categories. A weak but significant negative correlation was observed between HU and age (r = -0.22, p = 0.0039). In multivariate logistic regression, FFP classification (OR = 10.03, p < 0.001), Denis zone involvement (OR = 8.58, p < 0.001), and HU (OR = 1.14, p = 0.63) were evaluated for their predictive value. The model achieved 92 % accuracy (AUC = 0.93).

CONCLUSION: HU alone is not a strong standalone predictor of H-type sacral fractures but improves multivariate model performance when combined with anatomical and clinical variables. HU's inverse relationship with age supports its utility as a surrogate marker for bone quality, especially when DXA is unavailable.

PMID:40618422 | DOI:10.1016/j.injury.2025.112576

Injury. 2025 Jul 2;56(8):112577. doi: 10.1016/j.injury.2025.112577. Online ahead of print.

ABSTRACT

INTRODUCTION: Hip fracture repair is one of the most common urgent procedures performed in hospitals. Having a high burden of mortality, hip fracture repair is frequently targeted for health system quality improvement and hospital performance monitoring. In the present study, we measure hospital variability and explore factors associated with 90-day mortality and the time from emergency department (ED) visit until surgery.

METHODS: Patients were 50-105 years of age at the time of their hip fracture surgery between fiscal years 2015/16 and 2023/24 in Ontario Canada. Hospital variation was measured using random intercept models, risk-adjusted mortality rates, and funnel plots. Risk-adjusted mortality was computed as observed/expected (O/E) ratios multiplied by the population mortality rate. Expected mortality was estimated using logistic regression or CatBoost machine learning methods adjusted for age, sex, comorbidity, and other measures of healthcare utilization. Funnel plots were presented using crude and risk-adjusted mortality by hospital volume. Bootstrap sampling was used to compute 95 % confidence intervals.

RESULTS: A total 12,607 deaths (12.1 %) occurred within 90 days of hip fracture repair (N = 103,887), 4488 (36 %) of which occurred in hospital. Hospitals only accounted for 0.6 % of the total variation in 90-day mortality. Other predictors of mortality included older age, male, higher comorbidity score, facility transfer, pre-operative anemia, home care, residence in long-term care, no prior receipt of anti-osteoarthritic medication, and no previous bone-mineral density scan (p < 0.0001 for all). Hospitals accounted for 9.2 % of the variability in the odds of receiving surgery within 48 h of ED visit. There was no clear cut-point of the time from ED arrival until surgery on the risk of 90-day mortality. There was no ecological association between hospital performance on timeliness (receipt of surgery within 48 h) and performance on 90-day mortality.

CONCLUSION: There was little hospital variation in 90-day mortality. Using three different approaches, there were a few hospitals that consistently stood out as performing better/worse than expected. There was more substantial variation in the time until treatment across hospitals, but the relationship between the time until surgery and 90-day mortality was tenuous.

PMID:40618421 | DOI:10.1016/j.injury.2025.112577